DENTAL TECHNIQUE

M-i-M for DME: matrix-in-a-matrix technique for deep margin

elevation
Pascal Magne, DMD, PhD

Localized subgingival margins ABSTRACT

constitute a challenge when Deep margin elevation is a solution to the problem of localized subgingival margins when
preparing a tooth for direct, preparing a tooth for direct, semidirect, or indirect restorations. The technique focuses on the
semidirect, or indirect restora- local isolation of the deep margin by using a modified circumferential matrix. An evolution of
tions, especially in patients the technique is presented, the matrix-in-a-matrix technique, to facilitate the isolation and fit of
with large class 2 restorations. the subgingival matrix by adding a sectional band inside the circumferential matrix and packing
Endodontics, tooth prepara- Teflon tape between the 2 bands. Resective surgeries, invasive restorative procedures, and even
sometimes extractions can all potentially be avoided by this modified deep margin elevation,
tion, isolation, impression
allowing ideal conditions for scanning or impression making. (J Prosthet Dent 2021;-:---)
making, and restoration de-
livery are all affected by the
problem of subgingival margins, which has traditionally facilitates the isolation and fit of a subgingival matrix by
been resolved by a surgical approach (apical displace- adding a sectional matrix inside the modified circumfer-
ment of supporting tissues).1-3 However, this resective ential matrix and further adapts the matrix by packing
approach has serious limitations because of anatomic Teflon tape between the 2 matrices. This modification of
considerations such as the adjacent cementoenamel the DME procedure should improve performance, mini-
junction, teeth with short root trunks, and adjacent root mizing the need for resective surgeries, invasive restor-
concavities and furcations. Maintaining such structures ative procedures, and even sometimes extractions. Sig-
after they are exposed by surgery is challenging and can nificant socioeconomic impact is also expected.
generate serious problems such as sensitivity, caries, or
periodontal disease. The surgical approach is also not TECHNIQUE
without consequences for the periodontal support of
adjacent teeth. Surgery can potentially be avoided by the 1. Evaluate the preoperative situation with the sub-
deep margin elevation (DME) technique,4 the principle of gingival box preparation, in this case for a mesio-
which was first described by Dietschi and Spreafico in the occlusal inlay (Fig. 1).
late 1990s.5 The subgingival margin is moved occlusally 2. Trim a circumferential matrix band (Tofflemire
by a directly placed composite resin restoration base. The Universal, Miltex-Integra) by using scissors to
procedure gained popularity and was supported by decrease its height and increase its curvature (Fig. 2).
subsequent publications identifying its safety and efficacy 3. Isolate the tooth with a dental dam or another
from a clinical, biological, histological, and mechanical isolation system (Isovac 2; Zyris, Inc), place the
standpoint.4,6-22 The fundamentals of DME have been modified matrix in a holder (Type 72, Hu-Friedy),
described elsewhere.23 One of the tenets, however, is and insert around the tooth to be treated (Fig. 3).
the successful isolation of the deep margin by using a Push the matrix as cervically as possible, and
modified circumferential matrix.4 An evolution of the tighten to hold in position. Note the lack of a seal
technique, the matrix-in-a-matrix technique (M-i-M),4,23 (arrow in Fig. 3).

The Don & Sybil Harrington Professor of Esthetic Dentistry, Herman Ostrow School of Dentistry of USC, University of Southern California, Los Angeles, Calif.

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Figure 1. Localized subgingival margin in mesio-occlusal inlay Figure 2. Regular Tofflemire matrix band modification (according to B.
preparation simulated on Typodont. Gergis, Adelaide, Australia) for deep margin elevation.

Figure 3. Modified matrix in place. Note residual gap at deepest part of Figure 4. Preparation of additional small matrix from end of matrix
gingival margin (arrow). band.

4. Prepare a small sectional matrix by cutting the end

segment from a universal matrix (Fig. 4). The width
of the matrix must be slightly greater than the size
of the proximal defect.
5. Loosen the circumferential matrix, and insert the
sectional matrix between the circumferential matrix
and the prepared tooth in the area of the sub-
gingival defect. Slide the sectional matrix apically
beyond the gingival margin (Fig. 5). Slightly
tighten the circumferential matrix to hold the po-
sition of the sectional matrix.
6. In teeth with concavities or without a gingival seal
(fluid, bleeding), use a cord-packing instrument or
periodontal probe to insert a small piece of Teflon Figure 5. Insertion of additional small matrix between tooth and
tape (sterilized plumber’s tape) between the circumferential matrix band. Gingival margin now closed (arrow in inset).
circumferential and sectional matrices (Fig. 6). Pack
the Teflon tape as apically as possible to ensure 7. Remove any blood or debris by cleaning the
that the sectional matrix is pushed against the gingival margin by using an oscillating instrument,
gingival margin of the subgingival defect (Fig. 7). preferably hemispherical (Sonicflex Microtip #32

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Figure 6. For patients with root concavities or insufficient seal by inner Figure 7. Teflon tape packed at gingival level between 2 matrix bands to
matrix, use thin instrument to insert small piece of Teflon tape between secure seal. Cross-sectional view showing packed Teflon tape pushing
2 matrices. inner matrix against margin for optimal seal (arrow in schematic inset).

Figure 8. Any blood or debris cleaned with hemispherical oscillating Figure 9. Following bonding steps (IDS), placement of 1 to 3 increments
instrument. Margin sealed and freshly cut for bonding (right inset). of elevation composite resin.

Figure 10. Following air-blocking, polymerization, and removal of Figure 11. Flash at gingival margin removed with hemispherical
matrices and Teflon tape, hand instruments (scaler or modified #12 oscillating instrument.
scalpel blade) used to remove resin flash in accessible areas.

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Figure 12. Ideal margin is now easily accessible for scanning or
impression (left). Tooth removed from Typodont (right) to show smooth
surface of elevation composite resin and optimal adaptation from matrix
fit (no polishing used).
and #33, Kavo) (Fig. 8). Rotary instruments can be
used too but might damage the internal surface of
the sectional matrix.
8. Dry and ensure that the margin is sealed, with no
fluid or bleeding.
9. Proceed to bonding steps (IDS including light-
polymerization), by using preferably a filled
radio-opaque adhesive system (Optibond FL
Unidose, Kerr) and placement of elevation
restorative composite resin (Fig. 9), 1 to 3 in-
crements of 1 to 1.5 mm each. Use a microbrush
(included in Optibond FL Unidose package)
slightly moistened with adhesive (adhesive,
Optibond FL Unidose) as the packing instru-
ment. Light-polymerize each increment for 20
seconds and an additional 10 seconds after air-
blocking the surface with glycerin gel (K-Y,
Johnson & Johnson).
10. Remove both matrices and Teflon tape, and pro-
ceed to hand-instrument finishing by using a #12
scalpel blade (Hu-Friedy) to remove resin flash in
accessible areas (Fig. 10).
11. Remove any excess at the gingival margin by
using an oscillating instrument (Fig. 11), prefer-
ably hemispherical (Sonicflex Microtip #32 and
#33) or tapered for inlays (Sonicflex Microtip #51
and #52).
12. Evaluate the fit of the direct elevation restoration
with a bitewing radiograph. Here, the tooth was
removed from the Typodont to demonstrate an
excellent margin and smooth composite resin
surface shaped by the inner sectional band
(Fig. 12).
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SUMMARY
A technique is presented to facilitate isolation of deep
subgingival margins in class 2 preparations by using a
modified circumferential matrix band and the M-i-M
technique. A sectional matrix was added inside the
modified circumferential matrix band, and Teflon tape
was packed apically between the 2 matrices. When fol-
lowed by proper adhesive procedures and elevation of
the margin with composite resin (DME), those teeth can
be treated more conservatively (direct or inlay or onlay
restorations) as opposed to the traditional approaches
(complete coverage crowns and/or surgical crown
lengthening).
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20. Bertoldi C, Monari E, Cortellini P, Generali L, Lucchi A, Spinato S, et al. Corresponding author:
Clinical and histological reaction of periodontal tissues to subgingival resin Dr Pascal Magne
composite restorations. Clin Oral Investig 2020;24:1001-11. Division of Restorative Sciences
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ultraconservative treatment options. Chicago: Quintessence; 2021. p. Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
360-4. https://doi.org/10.1016/j.prosdent.2021.11.021

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